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Role of Socio-Cultural Factors in Psychiatric Setting With Reference to Nepal

1. Background Nepal has a short and slowly developing history of psychiatry. Recent political turmoil has crippled Nepalese healthcare in rural areas. Although the final quarter of the 20th century saw some development of psychiatric services in Nepal, the majority of Nepalese people remain deprived of such services even today. There is no national health program or Mental Health Act. Psychiatric services are hospital based and most are centralized in the capital. The United Nations classifies Nepal as one of the least developed countries in the world, with a per capita income of just 150. Nearly two-fifths of the population lives on less than 90p a day. It is predominantly a rural country where only 15% of the population live in urban areas. Less than 3% of gross domestic product is spent on the healthcare system and only 0.8% of the healthcare budget is spent on mental health. There are no national morbidity data for mental illness either in primary or secondary care. The prevalence of mental disorders in Nepal apparently does not differ from that of other countries in the south Asia region. According to Dr Kan Tun (personal communication, 2006), the World Health Organization (WHO) representative to Nepal, around 1% of the population has severe mental illness and 10-20% milder mental health problems. A survey of two developing towns in western Nepal in 1998 revealed a high point prevalence (35%) of conspicuous psychiatric morbidity (Upadhyaya & Pol, 2003). About 2% of people with that degree of morbidity have been reported to suffer from incapacitating illnesses requiring continuous support. The current situation would certainly be different as a decade-long Maoist insurgency has caused immense social upheaval.

2. Introduction Psychiatry, as a branch of medicine pertaining to the study and treatment of mental disease (Tunner, 1984:551), has for the most part continued to ignore socio-cultural factors in its theoretical and applied approaches to mental disorders. Due to the significant influence of biological medicine on psychiatry, there has been a persistent focus on the disease conception regarding its study. This assumes that mental Kshitiz Gurung and Sanam Kala Rai MSW 1st year/ 2nd semester

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Role of Socio-Cultural Factors in Psychiatric Setting With Reference to Nepal


disorders are largely biologically caused illnesses, which are universally represented in etiology and manifestation. However, this notion is challenged through cross-cultural studies, and through the consequent emergence of trans-cultural psychiatry, which introduces socio-cultural factors into the understanding and treatment of mental disorders. Mental disorders affect human behavior, and behavior is culturally correlated, their symptoms, meanings and treatment of mental disorders are mediated by culture and society, and this will be demonstrated by examining socio-cultural determinants in a range of mental disorders, including depressive disorders, schizophrenia, eating disorders and somatisation. Hence, socio-cultural factors play significant role in mental settings; the case is more sensitive in cultural conscious societies.

3. National Mental Health Facilities Scenario Nepal is a rural country. The majority of its population depends on agriculture and farming. The complete absence of a social welfare net is a major obstacle to the development and delivery of mental healthcare. Most people think that mental illness means becoming crazy or lunatic, being possessed by spirits or losing control of oneself (Regmi et al, 2004). Although healthcare professionals are becoming more aware of mental health problems (Shyangwa et al, 2003), the majority of rural Nepalese people still believe that mental illness is caused by bad fortune. There are no national morbidity data for mental illness either in primary or secondary care. The prevalence of mental disorders in Nepal apparently does not differ from that of other countries in the south Asia region. According to Dr Kan Tun (personal communication, 2006), the World Health Organization (WHO) representative to Nepal, around 1% of the population has severe mental illness and 10-20% milder mental health problems. A survey of two developing towns in western Nepal in 1998 revealed a high point prevalence (35%) of conspicuous psychiatric morbidity (Upadhyaya & Pol, 2003). About 2% of people with that degree of morbidity have been reported to suffer from incapacitating illnesses requiring continuous support. The current situation would certainly be different as a decade-long Maoist insurgency has caused immense social upheaval. Kshitiz Gurung and Sanam Kala Rai MSW 1st year/ 2nd semester Page 2

Role of Socio-Cultural Factors in Psychiatric Setting With Reference to Nepal


The Government spends about 1% of the health budget on mental health. There is no mental health act and the National Mental Health Policy formulated in 1997 is yet to be fully operational. Mental ill health is not much talked about because of the stigma attached. The roles of the legal & insurance systems are almost negligible. The financial burden rests upon the family. The traditional/religious healing methods still remain actively practiced, specifically in the field of mental health. The service, comprising little more than two-dozen psychiatrists along with a few psychiatric nurses and clinical psychologists (mainly practicing in modern health care facilities) has started showing its impacthowever this is limited to specific urban areas. The majority of the modern health care facilities across the country are devoid of a mental health facility. The main contextual challenges for mental health in Nepal are the provision of adequate manpower, spreading the services across the country, increasing public awareness and formulating and implementing an adequate policy.

4. Social cultural factors and Psychology Human beings and their cultures are not separable but interdependent and reflective of one another. The culture of individuals will interact with biological, psychological and environmental variables to determine the causes and manifestations of mental disorder; human beings and their culture cannot be separated. Moreover, culture is not simply incidental to mental disorders and therapy. Rather, it is a basic variable that interacts with biological, psychological and environmental variables in determining the causes, manifestations and treatment of the entire spectrum of mental disorders (Marsella and White, 1982: ix). Whereas social factors like unemployment, migration, life stress, social perceptions, race, gender, class hierarchy, religion, conflicts, war, traditional mindset of the people and other factors play active role for people to suffers from psycho-social problems.

The effects of socio-cultural factors on form, course and outcome of major psychiatric disorders can be considered as pathoplastic, i.e., shaping rather than causing psychopathology. However, there are situations of socio-cultural change in which the stress of acculturation or deculturation exerts pathogenic effects which lead in a Kshitiz Gurung and Sanam Kala Rai MSW 1st year/ 2nd semester

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Role of Socio-Cultural Factors in Psychiatric Setting With Reference to Nepal


hitherto tradition directed population to the appearance of types of psychosocial pathology previously unknown in that population. Such a pathogenic process is the rapid socio-cultural change through overwhelming or imposed Westernization of small scale non-Western societies, as Henry Murphy already demonstrated in 1959 on the basis of the first available data [MURPHY 1961] The impact of rapid Westernization transforms small tradition-directed communalist societies, consolidated over many centuries, within a very short time into modern mass societies [WEBER 1972] This process of rapid socio-cultural change creates an anonymous impersonalization of social relationships which generates anomie, the loss of guiding norms of behavior [DURKHEIN 1897] It also leads to a conflict between modern Western notions and traditional non Western values which in turn creates cultural confusion and a widening gap between the models of an affluent Western life style as propagated by the media, and the often bleak socio-economic reality, thus causing feelings of relative deprivation. Anomie, together with cultural identity confusion and relative deprivation, are the principal pathogenic factors operating in the development of the psychosocial syndrome. The experiences of loss of traditional culture and of social marginalization under imposed Westernization have in many of the aboriginal First Nations of North America, including Alaska and Greenland, been reflected in a relatively high incidence of alcohol abuse and of juvenile suicide. The situation is very similar in some regions of the South Pacific [JILEK 1974; JILEKAALL 1974; KRAUS & BUFFLER 1979; HOCHKIRCHEN JILEK 1985; JILEK 1987; JILEK AALL 1988; THORSLUND 1990; RUBINSTEIN 1992; HEZEL 1993; KIRMAYER 1994]. Similarly, a study in social factors associated with illness status was conducted in an Australian suburban community. Forty six per cent of adults reported a chronic physical condition and twenty four per cent were psychiatrically impaired. Life event stress, adverse childhood experience and poor social support were related to both physical and psychiatric Illness. Low occupation status was associated with poor physical health and a poor coping style was associated with psychiatric Illness. Twenty per cent of the physical illness and thirty seven per cent of the psychiatric impairment could be attributed to the presence of social factors.

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Role of Socio-Cultural Factors in Psychiatric Setting With Reference to Nepal


5. Role of socio-cultural factors in psychiatric setting with reference to Nepal Nepal is home to several ethnic groups. The majority of the 23 million populations reside in the countryside. Although figures on many of the health and socio-economic indicators are non-existing, some existing ones show gradual improvement over the years. However the figures for illiteracy and infant mortality are still one of the highest in the world. As per GDP, and population living below the poverty line and per capita income, Nepal still remains one of the poorest countries in the world. With low literacy rate and poor socio-economic condition the people have poor living style. Moreover the country people have traditional and rustic feelings. The approximate financial burden that falls on a family when one of its members becomes mentally ill is around 25,000 Nepalese rupees (equivalent to nearly 200) per year. This financial burden has huge effect in every citizen of the country which has resulted in abroad migration among the youths (of both genders). An article about psychiatric morbidity in foreign job holders of Nepal from the journal of GMC- Nepal suggested that change in place of residence with its socio-cultural differences plays a role as stressors in precipitating psychiatric illnesses. The study concludes psychological and social distress appearing to be increasing worldwide as a direct effect of certain social changes, particularly related to migration. Change from original social milieu is associated with increased psychiatric morbidity. It also tells that mobility of male to foreign land leaving spouse and children back home may be an additional factor adding to the overall stressors. Nepal is influenced by the global village concept and affected by the wave of modernization and westernization. As mentioned above, much of the scholars have opined rapid social-cultural changes for the pathogenic factors for mental disorders; the increasing urbanization can hint for the changing mental health scenario of the country. Recent article in The Kathmandu Post newspaper daily read about increasing female morbidity due to suicide in the country. Suicide has become the biggest killer of Nepali women of reproductive age as of 2009, according to the Nepal Mortality and Morbidity study 2008/9. If poverty alone were the cause, evidence shows that the percentage of Kshitiz Gurung and Sanam Kala Rai MSW 1st year/ 2nd semester

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Role of Socio-Cultural Factors in Psychiatric Setting With Reference to Nepal


Nepalese living in absolute poverty has actually decreased significantly over the past two decades. So it traces that there is more than only the economic reasons for the impact. The article suggests legal, social, cultural, religious, and stigma- taboos as main hurdles and reason for unreported cases. Female oppression, discrimination, inequality in resource and opportunity distribution, traditional cultural stereo types and patriarchy on the top has been cited for the reasons for alarming number of female suicides. In Nepals context, the ever prevailing social issues like unemployment, gender discrimination, caste structure, caste discrimination, domestic violence and socio economic problems has created stress of different levels and subsequently caused problems in mental health. Economic and social insecurity, political instability, poor countrys administration, decade long insurgency has created generalized frustration among the country people. Discrimination based on race, color, sex, creed and national origins interferes with the opportunities of an individual which directly affect in human psychology. People often find themselves on psychological, physical and vocational defensive as a result of many types of institutional discrimination and socio-cultural factors in the society. Not to forget the rampant corruption, anarchy adding to these are fuel and price hikes, water and electricity shortages have always hindered the day to day life with stresses leaving the people in threshold of patience. So, of course, social and cultural factors like poverty, exclusion, inequality and gender violence are reasons for effects in mental health, but so are newer, often more potent ones like modernization, post conflict stress, and over all environmental and rapid societal changes. The cultural practices like Dhami- Jhankri for witchcraft Boksi are still prevalent in rural settings. Due to the cultural stereo types the people who are mentally ill dont access the psychologists, the people think that they will be regarded mentally sick and distinguished from the society.

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Role of Socio-Cultural Factors in Psychiatric Setting With Reference to Nepal


6. Role of social worker Because the social workers practice in a wide variety of setting, they are an ideal position to observe and study the effect of the mentally sick persons, race, castes, ethnic groups, and reference group on several important aspects of treatment. But the bitter reality is that we do not have professional social workers and the people who are educated in the most expensive college, migrate to the foreign countries and it is very sad to all of social work students of this age. The social workers can play vital role by advocating for the benefit of the patient, educating people to change the traditional mindset. Raising awareness about mental health and collaborating with the mental health professionals can be done. The family members will be informed about the problems and encourage the patient to cooperate accordingly. The people can be given the trainings to increase their income and to have a better livelihood through different community organizations. Providing education as the main strategy in the mental health cases, social workers can give lectures, pamphleting on mental health issues, and appropriate coverage of the event I the local news, radios and FM stations. The social worker can do the follow up of the cases and find out the improvement and its long term effect. Social works can provide the government and different agencies to modify their strategy and work in coordination with them to provide best for human kind.

7. References: Dhungel Bidushi, THE DEEP END, Kantipur Publications, The Kathmandu Post, Features, Saturday March 31 2012, Page 8 Nepal mental health country profile2004, Vol. 16, No. 1-2 , Pages 142149 S. K. Regmi, A. Pokharel, S. P. Ojha, S. N. Pradhan and G. Chapagain Psychiatric Bulletinpb.rcpsych.org; The Psychiatrist (2007) 31: 348-350 doi: 10.1192/pb.bp.107.014571

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Role of Socio-Cultural Factors in Psychiatric Setting With Reference to Nepal


School of Anthropology Archaeology and Sociology, AN1001:03, Discovering

Anthropology

THERELATIONOFSOCIALFACTORTOPHYSICALANDPSYCHIATRICILLNESS.ht m http://www.mentalhealth.com/mag1/wolfgang.html

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